What is the next best step in management for a patient with epigastric pain, negative H. pylori antibodies, and multiple duodenal ulcers?

From the Guidelines

The next best step in management for a patient with epigastric pain, negative H. pylori antibodies, and multiple duodenal ulcers is to initiate a proton pump inhibitor (PPI) therapy and consider additional testing with fasting serum gastrin. The patient's symptoms and EGD results showing modern gastritis and several ulcers in the duodenal bulb and the first and second portions, along with biopsies of the antrum showing acute and chronic inflammation, support the use of PPI therapy 1. A standard regimen would include omeprazole 20-40 mg, esomeprazole 20-40 mg, pantoprazole 40 mg, or lansoprazole 30 mg once daily for 4-8 weeks. The patient should take the medication 30 minutes before breakfast for optimal effect. Additionally, the patient should be advised to avoid NSAIDs, alcohol, smoking, and spicy foods that may exacerbate symptoms. Considering the patient's negative H. pylori antibodies, it's essential to consider other potential causes of duodenal ulcers, such as Zollinger-Ellison syndrome, which can be evaluated with fasting serum gastrin levels. The patient should be scheduled for follow-up in 4-8 weeks to assess symptom improvement. If symptoms persist despite PPI therapy, upper endoscopy should be repeated to evaluate healing and consider other diagnoses. PPIs work by irreversibly blocking the hydrogen/potassium ATPase enzyme system in gastric parietal cells, reducing acid production and allowing the ulcers to heal. This approach addresses the fundamental pathophysiology of duodenal ulcers, which typically develop when acid production overwhelms mucosal defense mechanisms. Key considerations in the management of this patient include:

• Initiating PPI therapy to reduce acid production and promote ulcer healing
• Considering additional testing, such as fasting serum gastrin, to evaluate for potential underlying causes of duodenal ulcers
• Advising the patient to avoid exacerbating factors, such as NSAIDs and spicy foods
• Scheduling follow-up to assess symptom improvement and evaluate the need for further testing or treatment.

From the FDA Drug Label

1. Indications and Usage Section 1 INDICATIONS AND USAGE 1.1 Treatment of Active Duodenal Ulcer Omeprazole delayed-release capsules are indicated for short-term treatment of active duodenal ulcer in adults. Most patients heal within four weeks. Some patients may require an additional four weeks of therapy.

The patient has multiple duodenal ulcers and negative H. pylori antibodies. The next best step in management would be to start the patient on a PPI (Proton Pump Inhibitor), such as omeprazole, as indicated in the drug label.

• Since the patient has multiple duodenal ulcers, it is essential to investigate the cause of the ulcers.
• Considering the patient has negative H. pylori antibodies, the most likely cause of the ulcers is not H. pylori infection.
• In this case, Fasting serum gastrin levels should be checked to rule out Zollinger-Ellison syndrome, a rare condition that can cause multiple duodenal ulcers. Therefore, the recommended next step is to check Fasting serum gastrin levels 2.

From the Research

Diagnosis and Management of Zollinger-Ellison Syndrome

The patient's symptoms, including epigastric pain, multiple duodenal ulcers, and negative H. pylori antibodies, suggest a possible diagnosis of Zollinger-Ellison syndrome (ZES) 3, 4.

• Key characteristics of ZES include:
  • Hyperchlorhydria-induced peptic ulcer disease
  • Chronic diarrhea
  • Gastrin-excess state caused by a duodenal or pancreatic neuroendocrine tumor
• Diagnostic tests for ZES include:
  • Fasting serum gastrin level measurement, which has a sensitivity of 99% 3
  • Secretin stimulation test to differentiate ZES from other hypergastrinemic states 3
  • Localization of the primary tumor and its metastases using endoscopic ultrasound or Gallium-68 radiotracers 3

Next Steps in Management

Given the patient's symptoms and negative H. pylori antibodies, the next best step in management would be to:

• Measure fasting serum gastrin levels to confirm the diagnosis of ZES 3, 5
• Consider a secretin stimulation test if the fasting serum gastrin level is elevated 3
• Start the patient on proton pump inhibitors (PPIs) to manage symptoms and reduce gastric acid production 3, 4

Additional Studies

Based on the patient's presentation, the following additional studies may be considered:

• Fasting serum gastrin level measurement to confirm the diagnosis of ZES 3, 5
• No additional studies are immediately necessary, but further evaluation may be needed to localize the primary tumor and its metastases if ZES is confirmed 3, 4